F0584

E

Failure to Maintain Adequate Linen Supply for Resident Hygiene and Comfort

Chicago, Illinois Survey Completed on 03-01-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not ensuring adequate clean linen, including towels and washcloths, for residents on the 3rd and 4th floors. One resident, a [AGE]-year-old with hemiplegia, cerebrovascular disease affecting the left dominant side, aphasia, cerebral infarction, type 2 diabetes with retinopathy, constipation, hypertension, GERD, hyperlipidemia, unspecified dementia, psychotic disturbance, mood disturbance, and anxiety, had a Brief Interview for Mental Status score indicating severe cognitive impairment and care plan goals to remain clean, dry, and odor free with appropriate cleansing and peri-care after each incontinent episode. On one survey day, a CNA reported that this resident needed incontinence care after a bowel movement but there were no towels or washcloths available, and the CNA was observed holding pieces of a cut-up sheet, stating she would have to use this to clean residents and that she had not been able to change residents all day due to lack of linen. The resident was observed lying in bed waiting to be changed while the CNA apologized and explained the absence of linen and towels.

Another resident, a [AGE]-year-old with bipolar disorder, schizoaffective disorder, asthma, cocaine dependence with cocaine-induced mood disorder, and hypertension, was cognitively intact per a recent Brief Interview for Mental Status. This resident reported that sometimes when he wanted to shower in the morning, there were no towels available on the floor. During the survey, a CNA on the 4th floor showed the clean linen room, which had no fresh linen, including towels, and stated that linen had not been delivered yet for her 7:00 a.m. to 3:00 p.m. shift and that residents complain when they want to shower and there are no towels. Laundry staff confirmed that the 4th floor had not yet received its linen delivery and that deliveries to other floors had occurred earlier in the morning, with the 4th floor typically receiving linen around 10:00 a.m.

Multiple staff interviews and observations documented ongoing linen shortages affecting both floors. On one day, the 3rd floor linen room had no towels, washcloths, or linens to make beds, and linen carts were empty, with CNAs stating they had not received linen/towels yet and were using a small amount left from the previous shift, causing some residents to wait for care until linen arrived. The housekeeping/laundry supervisor acknowledged that the 3rd floor linen cart should have been delivered earlier, that linen supplies were low at the end of the month while awaiting a new order, and that complaints about needing linen, towels, and washcloths were common. The facility’s extra linen room was observed to contain only limited remaining stock, and laundry logs showed minimal or no towels delivered to certain floors on specific dates, supporting the finding that the facility failed to maintain adequate linen supplies necessary to honor residents’ rights to a safe, clean, comfortable, and homelike environment.